ElderGrade

Inspection citations at Devonshire Oaks Nursing Center

28 citations on record, 1 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2025 6 0
2023 16 1
2021 6 0
D January 17, 2025 Tag F0849 Corrected Mar 2025

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

No actual harm, potential for more than minimal harm

D January 17, 2025 Tag F0755 Corrected Mar 2025

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D January 17, 2025 Tag F0684 Corrected Mar 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D January 17, 2025 Tag F0656 Corrected Mar 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D January 17, 2025 Tag F0655 Corrected Mar 2025

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

F January 17, 2025 Tag F0812 Corrected Mar 2025

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

D October 27, 2023 Tag F0623 Complaint investigation Corrected Jan 2024

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

No actual harm, potential for more than minimal harm

D October 27, 2023 Tag F0801 Corrected Nov 2023

Nutrition and Dietary Deficiencies

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

No actual harm, potential for more than minimal harm

D October 27, 2023 Tag F0761 Corrected Oct 2023

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

No actual harm, potential for more than minimal harm

D October 27, 2023 Tag F0732 Corrected Oct 2023

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

No actual harm, potential for more than minimal harm

D October 27, 2023 Tag F0657 Corrected Oct 2023

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D October 27, 2023 Tag F0655 Corrected Oct 2023

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

D October 27, 2023 Tag F0584 Corrected Oct 2023

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, potential for more than minimal harm

D October 27, 2023 Tag F0558 Corrected Oct 2023

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

No actual harm, potential for more than minimal harm

D October 27, 2023 Tag F0557 Corrected Nov 2023

Resident Rights Deficiencies

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

No actual harm, potential for more than minimal harm

D October 27, 2023 Tag F0550 Corrected Oct 2023

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

E October 27, 2023 Tag F0804 Corrected Nov 2023

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

E October 27, 2023 Tag F0803 Corrected Nov 2023

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

No actual harm, potential for more than minimal harm

E October 27, 2023 Tag F0802 Corrected Nov 2023

Nutrition and Dietary Deficiencies

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

No actual harm, potential for more than minimal harm

E October 27, 2023 Tag F0661 Corrected Oct 2023

Resident Assessment and Care Planning Deficiencies

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

No actual harm, potential for more than minimal harm

F October 27, 2023 Tag F0812 Corrected Nov 2023

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

G August 1, 2023 Tag F0689 Complaint investigation Corrected Sep 2023

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

D November 10, 2021 Tag F0802 Corrected Dec 2021

Nutrition and Dietary Deficiencies

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

No actual harm, potential for more than minimal harm

D November 10, 2021 Tag F0689 Corrected Dec 2021

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

E November 10, 2021 Tag F0812 Corrected Dec 2021

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

E November 10, 2021 Tag F0759 Corrected Dec 2021

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

No actual harm, potential for more than minimal harm

F November 10, 2021 Tag F0867 Corrected Dec 2021

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

No actual harm, potential for more than minimal harm

F November 10, 2021 Tag F0804 Corrected Dec 2021

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.